Krukenberg Progression of Gastric Carcinoma in Pregnancy: Is Early Diagnosis Possible? Case Report and Review of the Literature.

Krukenberg tumors are metastatic tumors of the ovaries, associated with poor outcomes. Most commonly, these tumors are of gastric origin. The diagnosis of Krukenberg tumors in pregnant patients is extremely rare and poses specific difficulties for clinicians. We report a case of a pregnant woman presenting with an unknown abdominal tumor. Through the use of magnetic resonance imaging, multiple differential diagnoses were proposed, including a malignant ovarian tumor. A cesarean section and explorative laparotomy were conducted, revealing Krukenberg metastases of a gastric tumor, discovered during intraoperative gastroscopy. Tumor resection with concomitant chemotherapy was conducted. The main aim of this paper was to evaluate whether earlier diagnosis seems possible in such cases. A thorough literature review was conducted, unfortunately revealing no reliable method for early detection. Furthermore, no consensus regarding diagnostics or therapy exists to date. Thus, more research should be conducted regarding this rare condition to offer recommendations regarding early detection, diagnostics, and therapeutic approaches.

Comparison of Ultrasound Descriptors of Abnormally Invasive Placenta (AIP) over the Course of the Second and Third Trimester-Is an Increase Verifiable?

Limited data exist regarding the course of abnormally invasive placentation (AIP) (=placenta accreta spectrum (PAS)) during the 2nd and 3rd trimester, although this knowledge would be important for optimal patient care. In this retrospective single-center longitudinal cohort study, potential aggravation of AIP was evaluated in 37 patients with ultrasound (US) pictures stored on a minimum of two visits. Five raters, blinded to diagnosis and gestational age, judged the degree of AIP as recommended by the International Society for PAS. The probability of invasiveness was estimated as absent, low, intermediate, severe (0-3 points), the extent as absent, focal, diffuse (0-2 points), and the presence and appearance of each US-sign as absent, mild, severe (0-3 points). None of the 10 judged signs appeared more severe (p ≥ 0.41) with progressing pregnancy. Neither the number of positively scored US-signs (earlier scan; 6.14 ± 2.06, later scan; 5.94 ± 2.16; p = 0.28), nor the estimated probability & extent of AIP rose (3.69 ± 1.15 vs. 3.67 ± 1.22; p = 1.0). Test-retest reliability corroborated excellent agreement between visits (mean number of positive US-signs ICC (3,1) = 0.94, 95% CI 0.91-0.97; p < 0.0001). Overall, there was no clinically detectable increase in invasiveness over the course of the 2nd and 3rd trimester. This should be further evaluated in prospective studies.

Performance of antenatal imaging to predict placenta accreta spectrum degree of severity.

INTRODUCTION: In cases of placenta accreta spectrum, a precise antenatal diagnosis of the suspected degree of invasion is essential for the planning of individual management strategies at delivery. The aim of this work was to evaluate the respective performances of ultrasonography and magnetic resonance imaging for the antenatal assessment of the severity of placenta accreta spectrum disorders included in the database. The secondary objective was to identify descriptors related to the severity of placenta accreta spectrum disorders. MATERIAL AND METHODS: All the cases included in the database for which antenatal imaging data were available were analyzed. The rates of occurrence of each ultrasound and magnetic resonance imaging descriptor were reported and compared between the Group "Accreta-Increta" (FIGO grades 1 & 2) and the Group "Percreta" (FIGO grade 3). RESULTS: Antenatal imaging data were available for 347 women (347/442, 78.5%), of which 105 were included in the Group "Accreta - Increta" (105/347, 30.2%) and 213 (213/347, 61.4%) in the Group "Percreta". Magnetic resonance imaging was performed in addition to ultrasound in 135 women (135/347, 38.9%). After adjustment for all ultrasound descriptors in multivariate analysis, only the presence of a bladder wall interruption was associated with a significant higher risk of percreta (Odds ratio 3.23, Confidence interval 1.33-7.79). No magnetic resonance imaging sign was significantly correlated with the degree of severity. CONCLUSIONS: The performance of ultrasound and magnetic resonance imaging to discriminate mild from severe placenta accreta spectrum disorders is very poor. To date, the benefit of additional magnetic resonance imaging has not been demonstrated.

Maternal and neonatal outcomes in planned versus emergency cesarean delivery for placenta accreta spectrum: A multinational database study.

INTRODUCTION: Placenta accreta spectrum (PAS) is a condition often resulting in severe maternal morbidity. Scheduled delivery by an experienced team has been shown to improve maternal outcomes; however, the benefits must be weighed against the risk of iatrogenic prematurity. The aim of this study is to investigate the rates of emergency delivery seen for antenatally suspected PAS and compare the resulting outcomes in the 15 referral centers of the International Society for PAS (IS-PAS). MATERIAL AND METHODS: Fifteen centers provided cases between 2008 and 2019. The women included were divided into two groups according to whether they had a planned or an emergency cesarean delivery. Delivery was defined as "planned" when performed at a time and date to suit the team. All the remaining cases were classified as "emergency". Maternal characteristics and neonatal outcomes were compared between the two groups according to gestation at delivery. RESULTS: In all, 356 women were included. Of these, 239 (67%) underwent a planned delivery and 117 (33%) an emergency delivery. Vaginal bleeding was the indication for emergency delivery in 41 of the 117 women (41%). There were no significant differences in terms of blood loss, transfusion rates or major maternal morbidity between planned and emergency deliveries. However, the rate of maternal intensive therapy unit admission was increased with emergency delivery (45% vs 33%, P = .02). Antepartum hemorrhage was the only independent predictor of emergency delivery (aOR: 4.3, 95% confidence interval 2.4-7.7). Emergency delivery due to vaginal bleeding was more frequent with false-positive cases (antenatally suspected but not confirmed as PAS at delivery) and the milder grades of PAS (accreta/increta). The rate of infants experiencing any major neonatal morbidity was 25% at 34+1 to 36+0  weeks and 19% at >36+0  weeks. CONCLUSIONS: Emergency delivery in centers of excellence did not increase blood loss, transfusion rates or maternal morbidity. The single greatest risk factor for emergency delivery was antenatal hemorrhage. When adequate expertise and resources are available, to defer delivery in women with no significant antenatal bleeding and no risk factors for pre-term birth until >36+0  weeks can be considered to improve fetal outcomes. Further studies are needed to investigate this fully.

Effectiveness of real-time continuous glucose monitoring to improve glycaemic control and pregnancy outcome in patients with gestational diabetes mellitus: a study protocol for a randomised controlled trial.

INTRODUCTION: Real-time continuous glucose monitoring (rt-CGM) informs users about current interstitial glucose levels and allows early detection of glycaemic excursions and timely adaptation by behavioural change or pharmacological intervention. Randomised controlled studies adequately powered to evaluate the impact of long-term application of rt-CGM systems on the reduction of adverse obstetric outcomes in women with gestational diabetes (GDM) are missing. We aim to assess differences in the proportion of large for gestational age newborns in women using rt-CGM as compared with women with self-monitored blood glucose (primary outcome). Rates of neonatal hypoglycaemia, caesarean section and shoulder dystocia are secondary outcomes. A comparison of glucose metabolism and quality of life during and after pregnancy completes the scope of this study. METHODS AND ANALYSIS: Open-label multicentre randomised controlled trial with two parallel groups including 372 female patients with a recent diagnosis of GDM (between 24+0 until 31+6 weeks of gestation): 186 with rt-CGM (Dexcom G6) and 186 with self-monitored blood glucose (SMBG). Women with GDM will be consecutively recruited and randomised to rt-CGM or control (SMBG) group after a run-in period of 6-8 days. The third visit will be scheduled 8-10 days later and then every 2 weeks. At every visit, glucose measurements will be evaluated and all patients will be treated according to the standard care. The control group will receive a blinded CGM for 10 days between the second and third visit and between week 36+0 and 38+6. Cord blood will be sampled immediately after delivery. 48 hours after delivery neonatal biometry and maternal glycosylated haemoglobin A1c (HbA1c) will be assessed, and between weeks 8 and 16 after delivery all patients receive a re-examination of glucose metabolism including blinded CGM for 8-10 days. ETHICS AND DISSEMINATION: This study received ethical approval from the main ethic committee in Vienna. Data will be presented at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03981328; Pre-results.

Trajectories of Fetal Adipose Tissue Thickness in Pregnancies After Gastric Bypass Surgery.

PURPOSE: Recent studies showed that women after surgery are at higher risk of delivering small-for-gestational infants. Thus, this study aims to investigate longitudinal changes of fetal subcutaneous adipose tissue thickness (FSCTT) of fetuses conceived after gastric bypass surgery as compared to BMI-matched controls. METHODS: Retrospective cohort study measuring ultrasound-derived longitudinal trajectories of abdominal FSCTT in 41 singleton pregnancies after gastric bypass surgery compared to 41 BMI-matched controls and 64 obese mothers. RESULTS: FSCTT was significantly lower in fetuses of women after GB as compared to BMI-matched controls in the second (mean difference 1.38 mm, p < 0.001) and third trimester of gestation (mean difference 3.37 mm, p < 0.001). Longitudinal analysis revealed significant differences in mean FSCTT trajectories between offspring's in GB mothers, BMI-matched, or obese controls. The ratio of FSCTT and abdominal circumference remained constant in the BMI-matched control group whereas it significantly decreased in fetuses of women after GB. Despite remarkable differences were observed in longitudinally assessed FSCTT, further analyses in the GB subgroup revealed that FSCTT were not influenced by OGTT mean or 120 min glucose values, biochemically hypoglycemia, time since bariatric surgery, or weight loss since surgery. CONCLUSION: In fetuses of mothers with history of bariatric surgery, abdominal FSCTT was markedly reduced. While the underlying mechanisms are not fully understood, a multifactorial genesis including nutritional deficiencies and altered metabolism after bariatric surgery is assumed.

Intrauterine Fetal Growth Delay During Late Pregnancy After Maternal Gastric Bypass Surgery.

PURPOSE: To investigate intrauterine fetal growth development and birth anthropometry of fetuses conceived after maternal gastric bypass surgery. MATERIALS AND METHODS: Longitudinal cohort study describing longitudinal growth estimated by ultrasound on 43 singleton pregnancies after gastric bypass compared to 43 BMI-matched controls. RESULTS: In fetuses after maternal gastric bypass surgery, growth percentiles decreased markedly from the beginning of the second trimester until the end of the third trimester (decrease of 3.1 fetal abdomen circumference percentiles (95 %CI 0.9-5.3, p = 0.007) per four gestational weeks). While in the second trimester, fetal anthropometric measures did not differ between the groups, the mean abdomen circumference percentiles appeared significantly smaller during the third trimester in offspring of mothers after gastric bypass (mean difference 25.1 percentiles, p < 0.001). Similar tendencies have been observed in estimated fetal weight resulting in significantly more SGA offspring at delivery in the gastric bypass group. In children born after maternal gastric bypass surgery, weight percentiles (32.12th vs. 55.86th percentile, p < 0.001) as well as placental weight (525.2 g vs. 635.7 g, p < 0.001) were significantly reduced compared to controls. CONCLUSION: In fetuses conceived after maternal gastric bypass, intrauterine fetal growth distinctively declined in the second and third trimester, most prominently observed in fetal abdomen circumferences. Birth weight and placental weight at birth was significantly lower compared to BMI-matched controls, possibly due to altered maternal metabolic factors and comparable to mothers experiencing chronic hunger episodes.

Risk-adapted management for vasa praevia: a retrospective study about individualized timing of caesarean section.

PURPOSE: Vasa praevia is a rare condition with high foetal mortality if not detected prenatally. There is limited evidence available to determine the ideal timing of delivery and management recommendations. The aim of this study was to critically review our experience with vasa praevia, with a focus on diagnosis and management. METHODS: In a retrospective analysis, all cases of vasa praevia identified in our department from January 2003 to December 2017 were included. All cases were diagnosed antenatally during sonographic inspection of the placenta, and individualized management for each patient was performed based on individual risk factors. 19 cases of vasa praevia were identified (15 singletons, four twins). 13 patients (79%) presented placental anomalies. In patients at high risk for preterm birth, caesarean delivery was performed between 34-35 weeks after early hospitalization and administration of corticosteroids, whereas in patients at low risk for preterm birth, caesarean section could be delayed to 35-37 weeks of gestation. Administration of corticosteroids was not obligatory in the latter cases. RESULTS: There were two acute caesarean sections, due to premature abruption of the placenta and vaginal bleeding. There was no maternal or foetal/neonatal death. None of the neonates required blood transfusion. There is limited evidence available with which to determine the ideal timing of delivery. CONCLUSION: However, our individualized, risk-adapted management, which attempts to delay the timing of caesarean section up to two weeks beyond the standard recommendation, seems feasible, with just two emergency caesarean sections and no case of foetal or maternal death.

Intra- versus retroplacental hematomas: a retrospective case-control study on pregnancy outcomes.

BACKGROUND: Intrauterine hematomas are a common pregnancy complication. The literature lacks studies about outcomes based on hematoma localization. Thus, we aimed to compare pregnancies complicated by an intraplacental hematoma to cases with a retroplacental hematoma and to a control group. METHODS: In a retrospective case-control study, 32 women with an intraplacental hematoma, 199 women with a retroplacental hematoma, and a control group consisting of 113 age-matched women with no signs of placental abnormalities were included. Main outcome measures were pregnancy complications. RESULTS: Second-trimester miscarriage was most common in the intraplacental hematoma group (9.4%), followed by women with a retroplacental hematoma (4.2%), and controls (0%; p = 0.007). The intraplacental hematoma group revealed the highest rates for placental insufficiency, intrauterine growth retardation, premature preterm rupture of membranes, preterm labor, preterm delivery <37 weeks, and early preterm delivery <34 weeks (p < 0.05), followed by the retroplacental hematoma group. When tested in multivariate models, intraplacental hematomas were independent predictors for placental insufficiency (ß = 4.19, p < 0.001) and intrauterine growth restriction (ß = 1.44, p = 0.035). Intrauterine fetal deaths occurred only in women with a retroplacental hematoma (p = 0.042). CONCLUSIONS: Intra- and retroplacental hematomas have different risk profiles for the affected pregnancy and act as independent risk factors.

Cervical length dynamics in triplet pregnancies: a retrospective cohort study.

PURPOSE: To review our experience with a screening program that included sequential cervical length measurements in our large population of triplet pregnancies. METHODS: Seventy-eight triplet pregnancies were retrospectively included. Cervical length measurements were performed by transvaginal ultrasound in 2-week intervals from week 16 + 0 onwards in a tertiary-care center in Vienna. The main outcome measurement was preterm delivery prior to 32 + 0 weeks of gestation. Statistical analyses were performed using paired and unpaired t tests and a stepwise linear regression model. RESULTS: There were 26 cases of preterm delivery (33.3%). Women with preterm delivery revealed significant cervical length shortening from week 22 + 0 (median 33 mm, interquartile range, IQR 17-39) to 24 + 0 (median 21 mm, IQR 7-30; p = 0.005). This was not observed in women without preterm delivery. From week 22 + 0 onwards, both groups showed further significant 2-week differences in cervical length (p < 0.05). Univariate analysis of cervical length in weeks 20 + 0, 22 + 0, and 24 + 0 as well as cervical length dynamics from 22 + 0 to 24 + 0 predicted preterm delivery. CONCLUSIONS: In triplet pregnancies, a decrease in cervical length seems physiological from week 22 + 0 onwards. A sharp decrease in cervical length from the 22 + 0 to the 24 + 0 week as well as the smaller cervical length in weeks 20 + 0, 22 + 0, and 24 + 0 increase the risk of preterm delivery.

Ten-Year Experience with the Conservative Management of Abnormally Invasive, Residual Trophoblastic Disease. A Retrospective Case Series.

Conservative management of abnormally invasive, residual trophoblastic disease (AIRTD) is underreported. We aimed at critically reviewing our experience with such conservative management. We conducted a retrospective cohort study that included 24 women. The median completed week of gestation at delivery (20/24, 83.3%)/2nd trimester miscarriage (4/24, 16.7%) was 35 (range 17-41). Two women initially chose a surgical treatment (dilatation and curettage), but AIRTD remained sonographically visible afterward. Five patients developed a fever >38.0°C for ≥2 days (5/24, 20.8%). Due to heavy vaginal bleeding, 2 patients then underwent dilatation, diagnostic hysteroscopy, and curettage (2/24, 8.3%). One of these women also had to undergo hysterectomy (1/24, 4.2%). The 23 patients without hysterectomy underwent regular sonographic follow-up examinations. Regression of AIRTD was found after a median of 74 days (range 36-323). In conclusion, our data suggest that a conservative, observational treatment is feasible in AIRTD, with low rates of secondary surgical interventions. The long time intervals until regression require perseverance by these patients.

Velamentous cord insertion as a risk factor for obstetric outcome: a retrospective case-control study.

PURPOSE: Velamentous umbilical cord insertion (VCI) is associated with adverse pregnancy outcomes. Literature lacks data on Doppler. We aimed to evaluate obstetric outcomes and results of uterine and umbilical artery Doppler flowmetry associated with VCI. MATERIALS AND METHODS: In a retrospective case-control study, 108 singleton pregnancies with VCI were age- and body mass index-matched to 108 singleton pregnancies without VCI. The main outcome parameters were obstetric outcome, pregnancy-related complications, uterine artery flowmetry at the second-trimester screening, and umbilical artery flowmetry before delivery. Statistical analysis was accomplished using Pearson's Chi-square test or Fisher's exact test, and the Mann-Whitney U test, where appropriate. RESULTS: Pregnancies with VCI revealed a significantly higher PI in the umbilical artery during the last measurement before delivery (1.00 ± 0.25 vs. 0.90 ± 0.10; p = 0.001). Gestational age at this measurement did not differ between the groups. Fetal malformations and intrauterine fetal death were more common in pregnancies with VCI (12.7 vs. 0 %; p < 0.001, and 6.5 vs. 0 %; p = 0.014, respectively). Patients with VCI delivered significantly earlier (36.2 ± 4.5 vs. 38.4 ± 2.6; p < 0.001). CONCLUSION: Higher rates of (early) preterm delivery were found in pregnancies with VCI. Fetuses with VCI also suffered from malformations and IUFD more frequently. The last pulsatility index value in the umbilical artery, before delivery, was significantly higher in pregnancies with VCI, which is of uncertain clinical value.

Influence of labor induction on obstetric outcomes in patients with prolonged pregnancy: a comparison between elective labor induction and spontaneous onset of labor beyond term.

BACKGROUND: Prolonged pregnancy is the most frequent reason for induction of labor. This study aims to determine the effects of labor induction on delivery outcome and to quantify the risks of cesarean delivery associated with labor induction in post-date pregnancies. PATIENTS AND METHODS: This retrospective case-control study included a total of 205 women who reached 42 weeks' gestation (41 weeks and 3 days) between January 2002 and April 2004 and who were scheduled for induction of labor with vaginal prostaglandins. These cases were matched for age and parity with controls in spontaneous labor beyond 41 weeks' gestation. Women with any additional medical or obstetric risk factors were excluded from the study. Maternal, neonatal and delivery outcomes were the main variables of interest. RESULTS: During the study period the data of 410 women were available for analysis. Our data revealed that the use of amniotomy (p=0.02), oxytocin (p=0.006) and epidural analgesia (p=0.001) was increased significantly in the induction group compared with the control group of women with spontaneous onset of labor beyond term. The frequency of cesarean delivery and vacuum extraction was also significantly higher in the induction group (p=0.0001). The Bishop score before induction was an important factor that affected the delivery outcome, resulting in significantly higher rates of cesarean section and vacuum extraction when the score was unfavorable (p=0.0001). A univariate regression model revealed induction per se (p=0.0001), primiparity (p= 0.0001), increased maternal age (p=0.006) and an unfavorable Bishop score (p=0.0001) as statistically significant risk factors for cesarean section. In a multivariate logistic regression model, primiparity (p=0.03), increased maternal age (p=0.02) and an unfavorable Bishop score (p=0.01) remained independent risk factors for cesarean section. High infant birth weight was also an independent risk factor (p=0.03). CONCLUSIONS: Our data suggest that women undergoing labor induction because of prolonged pregnancy should be sufficiently informed regarding the risks of a cesarean section or a vacuum extraction. Furthermore, the option of elective cesarean section should be considered, particularly in primiparous women with an unfavorable cervix, higher age, and high estimated infant birth weight.